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007.05.4-11. General Requirements

AR ADC 007.05.4-11Arkansas Administrative CodeEffective: August 4, 2022

West's Arkansas Administrative Code

Title 007. Department of Health

Division 05. Health Facility Services

Rule 4. Rules for Home Health Agencies in Arkansas

Effective: August 4, 2022

Ark. Admin. Code 007.05.4-11

007.05.4-11. General Requirements

Currentness

A) Policies and Procedures. The agency shall have annually reviewed, written policies including:

1) Organizational

(a) A description of the structure showing ownership and lines of authority down to the patient service level;

(b) The services offered;

(d) Criteria for patient acceptance, referral, transfer and termination; and

(e) An annual operating budget approved by the governing body and/or administrator.

2) Orientation of all personnel to the policies and objectives of the agency;

3) Personnel policies;

4) Procedures for all tasks and patient care;

5) Reporting changes in patient condition;

6) Agency-wide Infection control program:

(a) which has as its goal the prevention and control of the spread of infection and communicable disease;

(b) which has work restrictions according to CDC recommendations; and,

(c) has measures for prevention of communicable disease outbreaks, especially Mycobacterium Tuberculosis (TB). All plans for the prevention of transmission of TB shall conform to the most current CDC Guidelines for preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities.

7) A personnel record shall be maintained for each employee. A personnel record shall include, but not be limited to, the following:

(a) job description signed by the employee;

(b) qualifications, education, and/or training;

(d) criminal history checks as required by Ark. Code Ann. § 20-38-101 et. seq.;

(e) verification of licensure, permits, references, job experience, and educational requirements as appropriate;

(f) performance evaluations and disciplinary actions; and

(g) verification of work history.

8) An agency-wide Quality Assurance and Improvement Program that includes all services for the purpose of monitoring the safety and effectiveness of services and quality of care. The program must include:

(a) client satisfaction surveys;

(b) supervision of services;

(d) performance improvement projects as applicable.

9) Complaints and Incidents. Each agency shall keep a record of complaints and incidents. Documentation shall include:

(a) the names of involved individuals;

(b) the relationship to the patient;

(d) date of complaint incident; and

(e) the action taken to resolve the complaint incident including referrals to other entities.

B) Governing Board. A Home Health Agency shall have an organized Governing Board consisting of at least one member, who may be the owner, who shall be legally responsible for maintaining quality client services and establishing policies for the agency, shall be legally responsible for the conduct of the agency and shall establish a mechanism to:

1) Approve a quality assurance plan whereby problems are identified, monitored and corrected;

2) Adopt and periodically review written bylaws or an acceptable equivalent;

3) Approve written policies and procedures related to safe, qualified and adequate provision of clinical services and operation of the agency.;

4) Appoint an administrator who is an employee of the agency or related institution.

5) Approve a plan for an alternate in the absence of the administrator; and

6) Oversee the management and fiscal affairs of the agency.

C) Administrator Responsibilities. The Administrator shall:

1) Manage the agency's daily on-going functions;

2) Employ qualified personnel and ensure appropriate ongoing education and supervision of personnel and volunteers;

3) Ensure the accuracy of public information materials and activities;

4) Implement and monitor the budgeting and accounting system; and

5) Ensure the presence of an alternate administrator to act in the administrator's absence.

D) Services Provided by Contractors

1) An Arkansas licensed home health agency may contract to provide services in the licensed agency's service area provided that administration, patient management and supervision down to the patient care level are ultimately the responsibility of the licensed agency;

2) A contracted entity or contracted individual conforms to all applicable agency policies, including those described in SECTION 11.A).

E) Patient Rights

1) The agency shall provide each patient and family with a copy of the Bill of Rights affirming the patient's right to:

(a) Be informed of the services offered by the agency and those being provided to the patient;

(b) Participate in the development of the plan of care and to be informed of the dates and approximate time of service;

(d) Be informed of the name of agency and how to contact that agency during all hours of operation;

(e) Be informed of the process for submitting and addressing complaints to the agency and be notified of the State Home Health Hotline number;

(f) Be informed orally and in writing of any charges which insurance might not cover and for which the patient would be responsible;

(g) Courteous and respectful treatment, privacy and freedom from abuse and discrimination;

(h) Confidential management of patient records and information;

(i) Access information in the patient's own record upon request

(j) Receive prior notice and an explanation for the reasons of termination, referral, transfer, discontinuance of service or change in the plan of care;

(k) Be informed of the right to voice grievances regarding treatment of care that is (or fails to be) furnished, and the lack of respect for property by anyone who is furnishing services on behalf of the agency and the right not to be subjected to discrimination or reprisal for doing so;

(l) Control access to the patient's home; and

(m) Be free from verbal, mental, sexual, and physical abuse including injuries from unknown source, neglect and misappropriation of property.

2) The agency shall provide each patient and family with a written list of responsibilities affirming the patient's responsibility to:

(a) Assist in developing and maintaining a safe environment;

(b) Treat all agency staff with courtesy and respect;

(d) Adhere to the plan of care or services as developed by the agency and to assist in the care as necessary.

F) Advance Directives

1) The agency shall have written policies and procedures regarding advance directives.

2) The agency shall inform and distribute written information to each patient on the initial evaluation visit concerning its policies on advance directives. Written information shall include notifying patients of their right to:

(a) Make decisions about their medical care;

(b) Accept or refuse medical or surgical treatment; and

G) Records and Documentation

1) The home health agency shall maintain records of all services provided to patients which are orderly, intact, legibly written and available and retrievable either in the agency or by electronic means and suitable for photocopying or printing.

2) Records shall be stored in a manner which:

(a) Prevents loss or manipulation of information;

(b) Protects the record from damage; and

3) Records shall be retained according to State and Federal laws.

4) Each record shall include:

(a) Assessments and evaluations

(b) Plans and assignments;

(d) Date and time employees or contracted individuals are in the home; and

(e) Tasks completed.

5) The following shall be included, if applicable;

(a) Physician, podiatrist and/or licensed practitioner orders;

(b) Records of supervisory visits.

(d) Any clinical notes;

(e) Records of case conferences; and

(f) Discharge summary.

6) Clinical notes are to be written the day the service is rendered and incorporated into the record no less often than every 14 days.

7) Provisions shall be made for the protection of records in the event an agency ceases operation.

Credits

Amended May 1, 2010; June 15, 2020; Aug. 4, 2022.

Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.

Ark. Admin. Code 007.05.4-11, AR ADC 007.05.4-11

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